California, physician's duty to care:
While the University of California explains the concept of legal duty to care, it addresses only those doctors who are 'hospitalists' or affiliated with a hospital, though we can draw the conclusion that the specific language of the law could interpret this to mean any physician with whom a patient has a relationship.
Department of Medicine, Program in Medical Ethics, Division of General Internal Medicine, University of California, San Francisco 94143, USA.
"In a hospitalist system, when a patient leaves the hospital, he or she will return to a primary care provider (PCP) for follow-up and continuing care. The hand-off after discharge can compromise communication with the PCP. Physicians have a legal duty to provide follow-up care to patients with whom they have a relationship. The obligation to provide follow-up care endures even when the patient misses a scheduled appointment or does not adhere to the follow-up regimen. In general, the physician who began the care must fulfill that obligation. An essential component of follow-up care includes educating the patient about what symptoms require follow-up care and why it is important. The duty to provide adequate follow-up care is shared by the hospitalist and the PCP. Virtually no malpractice case law considers the obligations and practices of hospitalists."
What this passage doesn't address is ongoing normative care but only that followup care resulting from a physician's primary care of the patient (i.e., a heart transplant patient MUST be given followup care regarding the requirements of post operative infection, medication and associated longterm prevention).
However, as to the ethics question:
“Physicians have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice sufficiently long in advance of withdrawal to permit another medical attendant to be secured.”
Source, American Medical Association Code of Ethics
The first step in avoiding an abandonment claim is to be sure that patients are not dismissed without adequate cause. What constitutes “adequate cause” is of course open to debate, but generally physicians may ethically refuse to treat a patient for any of the following reasons:
1. Routinely fails to pay bills for services rendered, even after repeated warnings.
2. Receives reimbursement through Medicare, but is left without a payment option when Medicare changes its reimbursement rules such that services are left uncovered.
3. Is rude and abusive to you and your staff, or makes threats against your health or life.
4. Misses office visits on a regular basis without a valid excuse.
5. Alters prescriptions that you give to him or her before filling them, or visits a second physician to get duplicate prescriptions. You may also terminate the PPR if you suspect the patient of using you to get prescription drugs or of redistributing the medications you do prescribe.
Failure to comply with the physician’s treatment plan may also constitute grounds for dismissal. In 1982’s Payton v. Weaver, a California court ruled that a physician was not obligated to continue treating a patient with end-stage renal disease because that patient missed multiple dialysis appointments, did not abide by the doctor’s prescribed dietary restrictions, and continued to use illegal drugs in spite of their impact on her treatment.
Now, as to our specific case, the PPR has not been terminated. The only thing that occurred in this instance is that treatment for a non-continuing case was refused due to the inability of the responsible party to pay for treatment. Although, later, it was discovered that the child suffered a very dangerous condition which resulted in surgery, the physician cannot be held legally liable in this case. In fact, from my reading of the AMA journals and my search (albeit cursory) of relevant medical organizations, while a bit questionable as to timeframe and practice, I see this physician as not illegally notifying patients of a new payment policy.
Remember, although her child was ill, this physician did not refuse to see the child or offer treatment. The practice simply informed her of a new payment policy and it was well within her right to come back when that policy could be adhered to. That the child was later seen by the emergency room (and we don't know how long from the time of this incident) is immaterial to the question of the physicians right to set office policy.
That being said, if this physician had been treating the child for an appendix that "MIGHT" rupture in the future and this visit was to insure the temperature and other signs were not in fact a rupture, then yes, the doctor could be held legally liable for refusing continuing care of the patient.
so far, this is where I am. And I'm probably never going to reach a solid conclusion on this simply because the case law and statutes are being re-written as we type. Even the AMA is fluidly continuing to update their policy statements todate.
An excellent start would be the discussions here:
http://www.mdnetguide.com/specialty_editions/menshealth/urology/feature.html
http://www.aafp.org/fpm/20040400/17whye.html
http://www.shands.org/professional/ppd/practice_article.asp?ID=145
